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Reimbursement Overview Calendar Year 2008. Outline for Today Overview of Benign Prostatic Hyperplasia (BPH) PROSTIVA ® RF Therapy Coverage and Coding.

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Presentation on theme: "Reimbursement Overview Calendar Year 2008. Outline for Today Overview of Benign Prostatic Hyperplasia (BPH) PROSTIVA ® RF Therapy Coverage and Coding."— Presentation transcript:

1 Reimbursement Overview Calendar Year 2008

2 Outline for Today Overview of Benign Prostatic Hyperplasia (BPH) PROSTIVA ® RF Therapy Coverage and Coding for PROSTIVA Physician Reimbursement Hospital Outpatient Reimbursement Ambulatory Surgery Center (ASC) Reimbursement

3 Symptomatic BPH Population US Prevalence:14.9 Million US Incidence: 500,000 Translates to:50% of men over 50 60% of men over 60 70% of men over 70 80% of men over 80 US Census; Millennium Research, 2006; A.G. Edwards & Son, Overview of BPH

4 Prostate Enlargement The prostate goes through two periods of growth. The first occurs early in puberty when the prostate doubles in size. At around age 25, the prostate begins to grow again and often results, years later, in a condition called an enlarged prostate. The medical term for this condition is called Benign Prostatic Hyperplasia (BPH). Overview of BPH

5 BPH Defined BPH is the most common nonmalignant disorder of the prostate and is characterized by prostatic enlargement, obstruction of the bladder outlet, and voiding symptoms. BPH is also referred to as Benign Prostatic Hypertrophy –Hyperplasia describes the process where cells increase in numbers –Hypertrophy describes the increase in cell size –Hyperplasia is the predominant process Overview of BPH

6 How Does BPH Affect Urination? BPH is a non-cancerous enlargement of the prostate As the prostate enlarges, it presses against the urethra like a clamp on a garden hose This can obstruct the flow of urine through the urethra Overview of BPH

7 How Does BPH Affect Urination? The bladder wall becomes thicker and irritable and begins to contract even when it contains a small amount of urine. These contractions cause the bladder to weaken so it does not completely empty. Overview of BPH

8 Why Treat BPH? BPH is not cancer but it can lead to unwanted complications if not corrected Urine retention and strain on the bladder can lead to –Urinary tract infections –Bladder or kidney damage –Bladder stones –Incontinence When BPH is diagnosed and treated early, there is a lower risk of developing such complications Overview of BPH

9 PROSTIVA ® RF Therapy Safe and effective A single office visit, treatment of less than one hour Fewer side effects and adverse events when compared to traditional surgical treatments Covered by Medicare and Medicaid in all 50 states and many private insurance companies

10 Delivers low-level radio frequency energy into the middle of the prostate and relieves obstruction without causing damage to the urethra Can be performed with a sedative and local anesthetic in a urologist’s office Procedure takes less than one hour Catheterization, if required, is zero- two days on average Intended for men over age 50 PROSTIVA ® RF Therapy

11 Indication for Use PROSTIVA ® radio frequency therapy is indicated for the treatment of symptoms due to urinary outflow obstruction secondary to benign prostatic hyperplasia (BPH) in men over the age of 50 with prostate sizes between 20 and 50 cm 3. PROSTIVA ® RF Therapy System User Guide. PROSTIVA ® RF Therapy

12 Disclaimer Medtronic has compiled this coding information for your convenience. It is always the provider’s responsibility to determine coverage and submit appropriate codes, modifiers, and charges for the services that were rendered. Contact your local carrier/payor for interpretation of appropriate coverage and coding policies. For unapproved uses, consult with your local carrier/payor before seeking reimbursement for use of a product that may be inconsistent with or not expressly specified in the FDA cleared or approved labeling (manual). Some payors may have policies that make it inappropriate to submit claims for such items or related services.

13 Coverage and Coding There is currently no National Coverage Determination (NCD) for PROSTIVA/TUNA*; however many states have local policies. The CPT code for PROSTIVA (53852) is on the Medicare Fee Schedules for 2008 (Physician, Hospital Outpatient, and ASC). Many commercial payors have written coverage policy for PROSTIVA/TUNA* *Note: Most policies for PROSTIVA will be listed under “TUNA.” Providers should refer to the applicable coverage policy! Coverage for PROSTIVA – Applicable Policies

14 Coverage and Coding CMS requires 5 digit ICD-9 Diagnosis Codes See our PROSTIVA reimbursement guide for common diagnosis codes. Coverage for PROSTIVA – Diagnosis Coding Providers should refer to the applicable coverage policy for diagnosis coding!

15 Coverage and Coding Indications must be documented (vary by state) –BPH of Significant Degree to Cause An AUA symptom score of 11 or higher Urine flow rate of 15 cc/sec. or less on a voided volume of 125 cc or more Volume of the prostate less than 65 gms on a transrectal ultrasound of the prostate Failed trial of voiding with an alpha-blocker medication, or tolerance to alpha- blocker Coverage for PROSTIVA - Typical LCD Language

16 Coverage and Coding Common contraindications may include: –Prostate or Bladder Cancer –Neurogenic, decompensated or atonic bladder –Prior non-drug treatment (eg TURP, Laser, TUMT) –Presence of other device that could interfere, eg penile implant, pacemaker, ICD, neurostimulator –Prostate size less than 34 mm or greater than 80 mm tranverse diameter –Active cystolithiasis, gross hematuria, urethral stricture acute prostatitis, diabetes mellitis affecting bladder function –Active urinary tract infection –ASA class group V patients Coverage for PROSTIVA - Typical LCD Language Providers should refer to the applicable coverage policy for medical necessity criteria!

17 Coverage and Coding The CPT Code for PROSTIVA is: CPT® is a registered trademark of the American Medical Association. Current Procedural Terminology (CPT) is copyright 2005 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. Coding for PROSTIVA

18 Coverage and Coding Transurethral destruction of prostate tissue; by radio frequency thermotherapy Coding for PROSTIVA CPT® is a registered trademark of the American Medical Association. Current Procedural Terminology (CPT) is copyright 2005 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.

19 Coverage and Coding “Workup” codes for PROSTIVA commonly include: –Office Visit (CPT Codes or ) –Electro-Uroflowmetry (CPT Code 51741) –Cystoscopy (CPT Code 52000) –PSA (CPT Code 84153) –Urinalysis (CPT Code 81000–81003) –Office or Other Outpatient Consultation (New or Established Patient) (CPT Codes ) Coding for PROSTIVA CPT® is a registered trademark of the American Medical Association. Current Procedural Terminology (CPT) is copyright 2005 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.

20 Physician Reimbursement Non-Facility (Office) Rate: $2,959* Facility (Hospital or ASC) Rate: $595* The Non-Facility Rate is designed to cover the cost of the physician’s time, the disposable cartridge and any additional indirect expense (rent, nursing staff, etc.) This code has a 90-day global period. Physician Reimbursement: January – June 2008 *Indicates national average payment amount from Medicare – commercial payor reimbursement will be based on the provider’s individual contract with that payor.

21 Physician Reimbursement The global period describes the time interval for all related services and care included in a surgical procedure PROSTIVA Therapy – CPT – has a global period of 90 days The global period for PROSTIVA Therapy is inclusive of anesthetics, whether lidocaine or the use of a prostatic block Examples: PROSTIVA patient returns to office after three days for catheter removal – can the physician bill for an office visit? NO PROSTIVA patient sees the physician within the 90 days for continued concerns about their BPH, or for questions about the PROSTIVA procedure – can the physician bill for an office visit? NO Physician Reimbursement: January – June 2008 A Note on Global Periods:

22 Hospital Outpatient Reimbursement In 2008, CPT code maps to APC 0429 in the Medicare Outpatient Prospective Payment System (OPPS). APC 0429 has a national average payment rate of $2,879* There is no separate device code for the disposable PROSTIVA cartridge. Hospital Outpatient Reimbursement: 2008 *Indicates national average payment amount from Medicare – commercial payor reimbursement will be based on the provider’s individual contract with that payor.

23 ASC Reimbursement In 2008, CPT code maps to APC 0429 in the Medicare’s ASC Payment System. APC 0429 has a national average payment rate of $1,872* in an ASC setting There is no separate device code for the disposable PROSTIVA cartridge. Ambulatory Surgery Center (ASC) Reimbursement: 2008 *Indicates national average payment amount from Medicare – commercial payor reimbursement will be based on the provider’s individual contract with that payor.

24 PROSTIVA Reimbursement What is a modifier? –A modifier is used with CPT codes to denote special consideration on the code –PROSTIVA CPT Code is Two modifiers that are commonly associated with PROSTIVA are: –-53 Discontinued Procedure Example: PROSTIVA procedure was aborted partial way through –-59 Distinct Procedural Service Example: TRUS was performed on the same day as PROSTIVA

25 PROSTIVA Reimbursement Questions????

26 PROSTIVA® RF Therapy Indications: PROSTIVA RF Therapy is indicated for the treatment of symptoms due to urinary outflow obstruction secondary to benign prostatic hyperplasia (BPH) in men over the age of 50 with prostate sizes between 20 and 50 cc. Adverse Events: Side effects may include obstruction, urinary retention, bleeding, pain/discomfort, urgency, frequency and urinary tract infection. CAUTION: Federal law (USA) restricts this device to sale by or on the order of a physician. For a listing of indications, contraindications, precautions and warnings, please refer to the System User Guide.


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